Provider Demographics
NPI:1760464424
Name:KOFFORD MEDICAL CORP.
Entity type:Organization
Organization Name:KOFFORD MEDICAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:KOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:949-493-7777
Mailing Address - Street 1:24582 DEL PRADO
Mailing Address - Street 2:STE H
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3843
Mailing Address - Country:US
Mailing Address - Phone:949-493-7777
Mailing Address - Fax:949-388-7264
Practice Address - Street 1:24582 DEL PRADO
Practice Address - Street 2:STE H
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3843
Practice Address - Country:US
Practice Address - Phone:949-493-7777
Practice Address - Fax:949-388-7264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70574261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A705741Medicaid
CA00A705741Medicaid
W15364Medicare ID - Type UnspecifiedPROVIDER NUMBER